Trends in the Use of Buprenorphine in US Emergency Departments, 2002-2017

Buprenorphine is an effective treatment for opioid use disorder, and its use has increased over time in outpatient settings¹ and among commercially insured adults in the United States.² Although the American College of Emergency Physicians and other professional organizations have advocated for buprenorphine treatment initiation in emergency department (ED) settings,³ little is known about how often this practice occurs in EDs nationwide. We examined the trends of buprenorphine use in EDs in the United States from 2002 (when it was approved) through 2017.

This cross-sectional study used 2002-2017 data from the National Hospital Ambulatory Medical Care Survey, which provides nationally representative samples of ED visits.⁴ We examined ED visits by patients aged 18 years or older. From our examination of these visits, we estimated trends of visits during which buprenorphine was dispensed using generic names (ie, buprenorphine or buprenorphine-naloxone). We combined data into 2-year intervals to improve the stability of our estimates.⁴ We quantified the number of visits during which these medications were used per 100 000 ED visits. This study was deemed to be exempt from human subjects review by the Yale School of Medicine’s Institutional Review Board because we used publicly available, deidentified data. Study procedures followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.

We compared the proportions of ED visits during which buprenorphine was dispensed between 2002-2003 and 2016-2017 using an adjusted Wald χ² test. To test linear trends over time, we transformed the survey year range from 0 (for 2002-2003) to 1 (for 2016-2017). Odds ratios associated with this transformed variable represent change in the odds of proportion of medication use during ED visits across the entire study period. We further conducted subgroup analyses by age, sex, race/ethnicity, and region. Stata, version 15.1 MP/6-Core (Stata Corp) was used for all analyses, and we used the svy commands in that statistical software to account for multiple years and the complex survey sampling design of the National Hospital Ambulatory Medical Care Survey, including unequal probability of selection, clustering, and stratification.⁴ Two-sided P < .05 was used to test statistical significance.

Between 2002 and 2017, there were 441 475 ED visits during which buprenorphine was dispensed. Among the patients who received buprenorphine, the mean (SD) age was 39.1 (14.8) years, 49.1% were male, 66.3% were non-Hispanic White, 31.0% were non-Hispanic Black, and 92.7% were from urban areas. The use of buprenorphine increased from 12.3 per 100 000 ED visits in 2002-2003 to 42.8 per 100 000 ED visits in 2016-2017 (odds ratio for linear trend, 3.31; 95% CI, 1.04-10.50) (Figure). From 2002-2003 to 2016-2017, the use of buprenorphine increased linearly among individuals aged 19 to 44 years (from 10.4 to 38.4 per 100 000 ED visits; P = .02). The use of buprenorphine also increased over time in the Northeast (from 0.0 to 8.2 per 100 000 ED visits; P = .01) and metropolitan areas (from 12.2 to 42.8 per 100 000 ED visits; P = .03) (Table).

Buprenorphine use increased in EDs between 2002 and 2017, the years for which the most recent data are currently available. The increase in overall buprenorphine use could be attributed to an increase in opioid-related ED visits.⁵ Limitations include the assumption that all buprenorphine was provided for opioid use disorder and the lack of information on dosing, route of administration, formulation, or prescriptions written for ongoing treatment after ED discharge. It appears that the sampling strategy or data collection method in 2012-2013 was different from that used in other years because less buprenorphine use was captured.

Despite the limitations, the present study found increased use of buprenorphine in ED settings, a promising strategy for narrowing the treatment gap. Potential barriers to ED adoption of buprenorphine treatment initiation for untreated opioid use disorder have been identified,⁶ and research on strategies to address these should be prioritized.

Accepted for Publication: August 7, 2020.

Published: October 20, 2020. doi:10.1001/jamanetworkopen.2020.21209

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Rhee TG et al. JAMA Network Open.

Corresponding Author: Taeho Greg Rhee, PhD, MSW, Department of Public Health Sciences, School of Medicine, University of Connecticut, 263 Farmington Ave, Farmington, CT 06030 (rhee@uchc.edu).

Author Contributions: Dr Rhee had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rhee, Fiellin.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rhee.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rhee.

Administrative, technical, or material support: Rhee.

Supervision: D'Onofrio, Fiellin.

Conflict of Interest Disclosures: Dr D’Onofrio reported funding from the National Institute on Drug Abuse Clinical Trials Network for several research projects related to implementation of emergency department–initiated buprenorphine. Dr Fiellin reported receiving grants from the National Institutes of Health and Patient-Centered Outcomes Research Institute (PCORI) and personal fees from Springer Nature, Boston Medical Center, Boston University, University of New South Wales, University of Alabama, Birmingham, the US Department of Justice, Tufts University, the American Society of Addiction Medicine, the American Academy of Addiction Psychiatry, and the University of Kentucky outside the submitted work. No other disclosures were reported.

Funding/Support: In the past 3 years, Dr Rhee was supported in part by grant T32AG019134 from the National Institute on Aging. Dr Rhee is currently funded by grant R21MH117438 from the National Institute of Mental Health and by the Institute for Collaboration on Health, Intervention, and Policy (InCHIP) of the University of Connecticut.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: Further details of the data, including description of data use, questionnaires, sampling methodology, and data sets, are available on the National Ambulatory Medical Care Survey website (https://www.cdc.gov/nchs/ahcd/index.htm).